A Detailed Guide to Advanced Primary Care Management Medical Billing Requirements

Advanced Primary Care Management (APCM) is a comprehensive approach to primary care that involves coordinating and personalizing care for patients, particularly the ones with complex health needs. APCM services include elements of many existing care management and communication technology-based services that you might have already been billing for your patients. This payment package encompasses the major components of advanced primary care, such as chronic care management (CCM), transitional care management (TCM), and principal care management (PCM).  

As important as this field is, medical billing for APCM can be equally challenging. That is due to different factors – complex coding system, ambiguous documentation, regulatory compliance, coordination of care, fraud prevention, and administrative burden. The first simple step to address these challenges is to understand the billing requirements of APCM. This can help ensure improved reimbursement, compliance, efficiency and patient care, reduced billing errors, and better financial stability.  

The CMS established billing and payment guidelines for a new range of APCM services in the 2025 Medicare Physician Fee Schedule (MPFS) final rule. Read on to get a detailed idea of the medical billing requirements of advanced primary care management.  

APCM Eligibility Criteria

All Medicare beneficiaries, whether they have complex or stable health needs, qualify for APCM. Those who have chronic conditions would benefit the most from this service because it supports patients with a variety of health complexities. Billers can use EHR to select patients easily per the criteria of Centers for Medicare and Medicaid Services (CMS).   

Who Can Bill for APCM Services? 

You can bill for Advanced Primary Care Management services if: 

• You are a non-physician practitioner (NPP) or physician, including a clinical nurse specialist (CNS), physician assistant (PA) or nurse practitioner (NP).  

• You are responsible for providing all the primary care services to your patients.  

• You are the focal point for all the required healthcare services of your patients.  

• You have received verbal or written consent from your patient.  

APCM service codes are essential for primary care specialties, such as pediatrics, geriatric medicine, family medicine, and general internal medicine. You can bill APCM services once per patient every month if you satisfy the medical billing criteria.  

APCM Medical Billing and Coding Guidelines

Starting January 1, 2025, primary care organizations can use the codes below to bill accurately for APCM services:  

• HCPCS G0556: It is for patients who have one or a few chronic conditions. The reimbursement rate is 15 USD/month per patient. 

• HCPCS G0557: It is for patients who have two or more chronic conditions. The reimbursement rate is 50 USD/month per patient. 

• HCPCS G0558: It is for patients who have multiple chronic conditions. The reimbursement rate is 110 USD/month per patient. 

APCM Medical Billing Requirements: 13 Service Elements

To bill for APCM services, it’s a must to complete the following 13 elements when they are clinically appropriate for the individual patient:  

1. Patient Consent: Brief the patient on the service, acquire consent and document the same in the medical record. 
2. Visit Initiation: This is needed for new patients or the ones who have not visited in three years. 
3. Continuity of Care: Maintain consistency by scheduling consecutive routine appointments with the same team member.  
4. Alternative Care Delivery: It refers to care delivery options like expanded hours and/or home visits alternative to office visits.  
5. Comprehensive Care Management: Manage general clinical oversight and medications, ensure that preventive services are received and carry out assessments of systematic needs. 
6. Patient-Centered Care Plan: Develop and maintain a comprehensive electronic care plan accessible to the patients and care team.  
7. 24/7 Access to Care: Offer patients 24/7 access to the practitioner or care team for emergency healthcare needs.  
8. Coordination of Care Transitions: Coordinate transitions between different healthcare providers and environments, guaranteeing timely sharing of health information and subsequent communication. 
9. Ongoing Communication: Speak to different service providers and document communication about the patient’s preferences, goals, and requirements.  
10. Improved Communication Methods: Facilitate communications through digital means like patient portals, email, secure messaging or others. 
11. Population Data Analysis: Identify gaps in care and offer suitable additional interventions.  
12. Risk Stratification: Discern and target healthcare services to patients using data.  
13. Performance Measurement: Assess the use of certified EHR technology, total cost of treatment and quality of care.  

APCM Documentation Standards by CMS 

Thorough documentation is essential to satisfy CMS’s APCM compliance needs. Each adjustment to the care plan, care coordination effort, and patient interaction should be recorded to meet medical billing needs and show the continuity of care.  

Here are the guidelines set by CMS to document APCM services: 

• Team Collaboration Notes: Although only RHCs or FQHCs and general physicians can bill using APCM codes, CMS requires documentation of contributions from every care team member. This emphasizes the interdisciplinary approach to care.  

• Record of Patient Interactions: Document all communications with patients, including in-person visits, telehealth visits, and phone calls to maintain ongoing care.  

• Patient Consent: Document the initial consent to APCM services and any discussions about the benefits, costs, and care plan to ensure compliance with CMS regulations.  

Real-time, accurate documentation helps general physicians deliver quality patient care and uphold compliance under APCM.  

Don’t be overwhelmed by the special billing needs for advanced primary care management services! Simply outsource APCM medical billing services to a trusted revenue cycle management company that has a dedicated team of primary care billing experts. They are trained and experienced to meet the compliance requirements and CMS guidelines for APCM billing. By partnering with such experts, you can ensure proper reimbursement and adherence to billing standards.